Module #6:ICD-10 Z-Codes For more information on TCPI SANs please use this link: http://www.tcpisan.org/

HCDI Overview HCDI-SAN Learning Library: Overview Z-Codes HealthCare Dynamics, International – founded and led by clinicians 25+ years supporting Centers for Medicare & Medicaid Services (CMS) quality and population health programs NICHE: Policy to Practice Strategy focused on health care delivery systems and the quality/cost for vulnerable populations Customized learning and action platforms focused on clinicians, patients and health care systems HCDI-SAN Learning Library: Overview Z-Codes Introduction to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10-CM) Z codes are a special group of codes provided in ICD-10-CM for the reporting of factors influencing health status and contact with health services. Primary Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.

Learning Objectives: ICD-10 Z-Coding Upon completing review of this slide-deck presentation, participant will able to: Identify the “Gaps” in care related and contributable to the Social Determinants of Health Describe the influence of the Social Determinants of Health in determining an individuals continuing health care status Understand the significance of incorporating Z codes: Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychological circumstances) to improve healthcare for the “whole” patient

HCDI-SAN: Medical Coding Overview Medical coding is concerned with assigning the relevant code to the various diagnosis and treatments given to a patient, to facilitate their insurance claims. Medical coders study the patient’s medical records to determine the procedures performed on the patient by the doctor, surgeon, nurse and other members of the healthcare team. They check the doctor’s transcriptions, laboratory test results and other documentation relating to the patient’s treatment. If no further details or clarification is required, the medical coder assigns the correct diagnosis or procedure code for the corresponding service given to the patient and creates the claims to be paid by the insurance company. The codes are assigned using the Current Procedural Terminology (CPT) for procedures received by the patient and the International Classification of Diseases (ICD) for the physician’s diagnosis of the patient.

Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc.

HCDI-SAN: Medical Billing Overview Medical billing is concerned with checking the assigned medical codes and transmitting the claim.  Making use of special software developed to input the codes assigned by the medical coder, the medical biller forwards the insurance claim to facilitate the payment.  Once the insurance claim has been forwarded, the medical biller continues to be in touch with the patient and the insurance company to ensure the claim has been paid.  In case of delays, rejected or denied claims, the medical biller needs to liaison between the patient and the insurance company to sort out the matter and resubmit the claims with necessary adjustments if required by the insurance company.

Medical billing is a payment practice within the United States health system. The process involves a healthcare provider submitting, and following up on, claims with health insurance companies in order to receive payment for services rendered; such as treatments and investigations.

Z-Coding and Population Health Z codes can be used as principal or first-listed diagnosis in some circumstances, including aftercare and special therapies such as chemotherapy. What makes them particularly valuable for population health is their use in indicating whether patients carry a disease, have the residual of a past disease, or have another factor influencing their health status. Z codes, when properly used, can be powerful in reporting socioeconomic conditions that may influence a patient's health status. There are challenges to widespread Z code adoption for population health management, such as the sensitive nature of the questions required to collect comprehensive social determinant data.

Z-Coding and Value-Based Reimbursement Besides their impact on population health, the data collected by Z codes may also contribute to success under value-based reimbursement models, in large part due to their granular nature. Social determinant data can inform the design of two distinct types of alternative payment models: performance-based incentive payments and/or penalties, and population-based payments. On the population-based payment front, emerging reimbursement models, which include capitation and partial-capitation models, may motivate providers to be more attentive to social determinants. This information can also inform capitation payment arrangements. New types of payments designed to reimburse and therefore promote care management and case coordination activities can be refined using social data.

Overview: Social Determinants of Health Z code data on social determinants of health can supplement traditional clinical patient data to improve patient management. A practice identifying a defined process for collecting and aggregating data on social determinants of health is an important step toward patient population management and for practice transformation.

Leveraging Actionable Data from Z Coding Z codes: Z55-Z65 Persons with potential health hazards related to socioeconomic and psychological circumstances: Z55 Problems related to education and literacy Z56 Problems related to employment and unemployment Z57 Occupational exposure to risk factors Z59 Problems related to housing and economic circumstances Z60 Problems related to social environment Z62 Problems related to upbringing Z63 Other problems related to primary support group, including family circumstances Z64 Problems related to certain psychosocial circumstances Z65 Problems related to other psychosocial circumstances

Z Codes Incorporated Into the HCDI-SAN Caring For your Health Tool Copyright© HCDI Tool 2017 Z Code 56 Z Code 55 Z Code 59 Z Code 59.4

Z59: Problems related to housing and economic circumstance Patient Case Example 67 year old female homeless patient is seen for six month check-up. She has an 8th grade education, skips meals regularly, and has no transportation. Provider documents “PVD due to Diabetes” also denotes that patient is homeless due to problems with family. Condition ICD-10 CODE CMS RISK SCORE DEMOGRAPHIC SCORE RAF SCORE Z code Type II DM with peripheral E11.51 .508 .290 1.114 Z59.0 Peripheral Angiogram & Angioplasty .316 Risk Adjustment Factor Case Mix = 1 use average resources < 1 use fewer resources > 1 use greater resources Z59: Problems related to housing and economic circumstance

Z-Coding: EHRs, Documentation Sticking Points Two major factors influence Z-codes utilization. The first is the ability of an organization's EHR to properly capture the information. EHRs are continually undergoing updates, revisions, and widespread technology improvements. Current EHR systems bear little resemblance to the initial efforts of 10 to 15 years ago Z-Code Underutilization Continues Despite their potential impact on emerging care and reimbursement models, Z codes are still underutilized. There are several factors fueling the underutilization of Z-Codes, including the lack of a mandate requiring their use

HCDI-SAN: CMS Resources on Z-Codes ICD-10-CM Official Guidelines for Coding and Reporting FY 2018: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pdf The 2019 ICD-10-CM files below contain information on the ICD-10-CM updates for FY 2019. These 2019 ICD-10-CM codes are to be used for discharges occurring from October 1, 2018 through September 30, 2019 and for patient encounters occurring from October 1, 2018 through September 30, 2019. https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html

Leaving In Action: “Food For Thought” How might having data on patient SDoH affect how your office provides care? What experience does your practice have with 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10-CM)? Think of a recent patient case in which SDoH might possibly have contributed to a problem or a poor health outcome. What techniques/ methods do you currently have in place to identify and capture the Z-Codes for your patients? What techniques/ methods do you currently have in place to identify, capture, and address your patients SDoH conditions? How might your practice be more efficient and effective in connecting patients with SDoH related issues to local community resources?

Questions? Uchenna Okoli SDoH@hcdi.com 301-552-8803 www.hcdi.com For more information on TCPI SANs please use this link: http://www.tcpisan.org/ 17

Learning & Action Network Acronym Guide: AAPM: Advanced Alternative Payment Models APM: Alternative Payment Models CEHRT: Certified Electronic Health Record Technology CFYH Tool: ‘Caring for Your Health’ Social Determinants Indicator Tool CMS: Centers for Medicare & Medicaid Services HCDI: HealthCare Dynamics International LAN: Learning and Action Network MACRA: Medicare Access and CHIP Reauthorization Act MIPS: Merit Based Incentive Payment System PTN: Practice Transformation Network QPP: Quality Payment Program REaL Data: Race Ethnicity and Language Data SAN: Support and Alignment Network SDoH: Social Determinants of Health TCPI: Transforming Clinical Practices Initiative